Provider Demographics
NPI:1811950645
Name:MARY BLACK PHYSICIAN SERVICES LLC
Entity type:Organization
Organization Name:MARY BLACK PHYSICIAN SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:V
Authorized Official - Last Name:MCCOLLUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-253-8063
Mailing Address - Street 1:145B DILLON DR
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29307-1017
Mailing Address - Country:US
Mailing Address - Phone:865-253-8063
Mailing Address - Fax:864-582-5188
Practice Address - Street 1:170 RIDGEVIEW CENTER DR
Practice Address - Street 2:
Practice Address - City:DUNCAN
Practice Address - State:SC
Practice Address - Zip Code:29334-9635
Practice Address - Country:US
Practice Address - Phone:864-573-3124
Practice Address - Fax:864-582-5188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-11
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207X00000X
SC363A00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
800572901OtherTAX ID
SCGP4319Medicaid
SCGP4168Medicaid
SCGP4169Medicaid
SCGP4353Medicaid
SCGP4319Medicaid